Risks of Modern Radiology. Dr Grant Meikle Consultant Radiologist

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Tamsin Walsh
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1 Risks of Modern Radiology Dr Grant Meikle Consultant Radiologist

Current Appointments SDHB Consultant Radiologist Consultant Radiologist, Shareholder, Chairperson Otago Radiology

2 My Background Consultant Radiologist MBChB 1994 FRANZCR 2001 Musculoskeletal Imaging Fellowship 2001/2002 Canberra, Australia. Current Appointments SDHB Consultant Radiologist Consultant Radiologist, Shareholder, Chairperson Otago Radiology Ltd (Part of the Pacific Radiology Group) Honorary Senior Clinical Lecturer University of Otago Department of Medicine. Other commitments. Part 2 examiner FRANZCR External Advisor ACC Treatment Injury Claims Unit.

3 Talk Structure RADIATION ERROR COST/DEMAND PRIVACY

4 RADIATION

5 How it all started? Roentgen 1896 Mrs Roentgen s Hand

6 Hindsight is wonderful thing!

7 Radiation Effects

9 Doses of common exams Examination Dose (msv) Comparable Natural Background Radiation Additional Lifetime risk of Cancer Extremity Xray hours Negligible Spine Xray months Very Low CXR days Minimal CT Head 2 8 months Very Low CT Abdomen 10 3 years Low

10 What do the risks mean? Approximate additional risk of fatal cancer for an adult from an examination: Negligible: less than 1 in 1,000,000 Minimal: 1 in 1,000,000 to 1 in 100,000 Very Low: 1 in 100,000 to 1 in 10,000 Low: 1 in 10,000 to 1 in 1000 Moderate: 1 in 1000 to 1 in 500 Note: These risk levels represent very small additions to the 1 in 5 chance we all have of dying from cancer.

11 What do we do? ALARA principle. Increased Awareness. Balance between risks and benefits.

12 Justification The most important consideration is balancing the risk (radiation) against the clinical utility of the examination. EXAMPLES Stubbed toe 2 hrs ago, weight bearing normally but sore toe. Persistent bony knee pain without history of trauma and increasing lethargy and weight loss.

13 COST and DEMAND

14 Cost The cost of Imaging varies but is in the range of: Xray $0 - $150 US $0 -$300 CT $0 - $2000 MRI $0 - $2000 The cost of an Imaging Examination is dependent on many factors including:- Equipment. Staff (MRTs,Radiologists, Nurses, Clerical) IT. Public vs Private system. Government Funding/Insurance/ACC/Community Schemes.

15 Demand

16 Waiting Times

17 Cost Pressure

18 Where we stand.

19 Expectations from the MOH More for less in a more timely manner. Target Waiting Times CT/MRI 6 8 weeks Is this possible? How? Efficiency? Investment? Statement of Intent 2012/13 to 2014/15 Ministry of Health

20 Where s it going to go?

21 ERROR

22 To err is human, to forgive divine. Alexander Pope, An Essay on Criticism English poet & satirist ( )

23 Error Rate Error rates in Radiological Interpretation are believed to be around the 3.5% to 4% level. Historically when an adverse event occurs or a bad outcome occurs there is search for someone or something to blame. The problem areas in radiology in terms of error are:- Mammography and detection of breast cancer CXR in detection of lung cancer Missed Fractures Obstetric Ultrasound

24 Radiology is Unique Our dirty washing is stored digitally forever for scrutiny with a retrospectoscope. Not so with many other areas in medicine. Good and Bad.

25 What types of errors do Radiologists make? In the USA there are 3 main reasons why radiologists are sued. 1. Observer Errors. 2. Failure to suggest next appropriate step. 3. Failure to communicate in a timely and clinically appropriate manner.

26 An abnormality is simply not observed. Several overlapping subclasses Scanning error Dont look Recognition error Look but don t see Decision making error See but discount Satisfaction of Search Distracted by another finding Observer Errors

27 Background factors that contribute to error in Radiology Background of psychophysiological factors Alertness / Fatigue. Distracting factors. Phones / Noise / Pagers / Consults etc etc Previous Study Bias. Other Factors Volume of Information. Pressure for fast turnaround.

28 The NZ System Our legal system does not usually involve law suits like the USA but there are a number of avenues that can be pursued. HDC ACC MCNZ Civil Action In general the NZ system facilitates a more open approach to error and its prevention.

29 The NZ System On review of ACC TI and HDC cases involving Radiology Services a few threads stick out. Adequate Supervision. Communication. Waiting Times. Failure to act on a result.

30 Reason s Swiss Cheese Model of James Reason, British Psychologist who in 1990 introduced risk analysis and management systems to human error. Two approaches:- PERSON APPROACH Assigns blame for an error to an individual SYSTEMS APPROACH Acknowledges that humans make mistakes and errors are to be expected. Views error as a consequence and focuses on system failure and safeguards that could prevent a recurrence. Medical Error

31 Reason s Swiss Cheese Model of For an error to occur at a clinical level there is usually a convergence of two factors. ACTIVE FACTORS Human Factors LATENT FACTORS System Factors An active factor such as a human error will not usually cause an adverse event if safeguards are in place to prevent a system error Medical Error

33 What are Radiologists doing? Audit Mistakes meetings MCNZ requirement Peer Review Consensus review Blind peer review RaER Radiology Events Register Hospital and Practice quality systems. Accreditation CME/CPD (RANZCR and MCNZ)

34 What can you do? Good Clinical details Be aware of patient preparation and issues associated with it. Have a practice policy/system regarding action on report findings. Integrate IT systems If it doesn t seem correct then ask.

35 PRIVACY

36 PRIVACY The right of privacy is well laid out in the Privacy Act. There is also a drive to integrate patient information. PACS Info. Public / Private. Who can look. Collision Course Policy and Procedures required and a balance needs to be struck.

37 The Privacy Act The law is the law. Who can look? Privacy often important in an Imaging Setting Pregnancy Cancer Celebrities/Staff/VIPS

38 An Integrated Model and Common Patient Record

39 Collision Course? Need for sound policy and guidelines. Audit Trail required. Active engagement. What s the balance?

40 Conclusions Balance up the risks and benefits of a radiological examination. If not sure ask. Everyone should learn from mistakes. Be careful around privacy vs access. But most importantly.

41 STAY POSITIVE

42 Thanks for you're attention.

Error, Injury & Loss in Medical Imaging. Matthew J Fleishman MD MMM FACR

Error, Injury & Loss in Medical Imaging Matthew J Fleishman MD MMM FACR Disclosures: None Objectives 1. Magnitude of errors & $ losses 2. Basis for major errors 3. Strategies to mitigate error, injury